INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 5/14/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.
The findings include:
Two client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 5/14/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client records # 7 and 10.
Client # 7 was admitted on 11/5/2014 and was involuntarily terminated from the facility on 3/9/2015 for continuously not showing up for scheduled counseling sessions. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
Client # 10 was admitted on 11/17/2014 and was involuntarily terminated from the facility on 4/1/2015 for multiple consecutive positive urine screening results. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 7 and Client 10 were mailed termination letters on 6/19/15.
Any clients that leave against facility advice or stop attending treatment will receive a written termination letter via mail to inform of termination from program 30 days after non-attendance or sooner if deemed necessary or if client is terminated for any other reason involuntarily. If client decides to leave voluntarily, counselors will document in that client record. The lead counselor and program director will monitor as clients are being discharged from the program on a daily basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to complete a psychosocial evaluation upon intake in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of psychosocial evaluations were reviewed on 5/14/2015. The facility failed to complete psychosocial evaluations upon intake in client records 2, 3 and 7.
Client # 2 was admitted on 3/25/2015 and was still an active client at the time of the inspection. There was no documentation of a psychosocial evaluation in the client's record.
Client # 3 was admitted on 2/2/2015 and was still an active client at the time of the inspection. The client's psychosocial evaluation was incomplete as it was not signed and dated by the counselor.
Client # 7 was admitted on 10/22/2014 and discharged on 3/9/2015. There was no documentation of a psychosocial evaluation in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All biopsychosocials and assessments will be completed within the 30 day time period for all charts. This will be reviewed with each counselor on a weekly basis by program director and senior counselor. All clinicians will be required to bring each new biopsychosocial to supervision and to clinical team meetings. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 5/14/2015. The facility failed to document a treatment plan update at least every 60 days in client records # 4, 7 and 10.
Client # 4 was admitted on 10/9/2014 and discharged on 3/2/2015. A comprehensive treatment plan was completed for the client on 11/5/2014. There were no subsequent treatment plan updates documented in the client's record.
Client # 7 was admitted on 10/22/2014 and discharged on 3/9/2015. The last two treatment plans documented in the client's record were completed on 10/22/2014 and 1/22/2015.
Client # 10 was admitted on 11/17/2014 and discharged on 4/1/2015. The last treatment plan update documented in the client's records was completed on 1/29/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plans will be completed within the time frame: preliminary 30 days, comprehensive treatment plan and update treatment plans every 60 days for outpatient and every 30 days for intensive outpatient. This will be monitored by program director and senior counselor on a weekly basis. All clinicians will be required to bring each treatment plan to supervision and to weekly team meetings. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 5/14/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5 and 8.
Client record # 1 contained a treatment plan dated 4/6/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the week 4/19/2015 - 4/25/2015.
Client record # 2 contained a treatment plan dated 4/25/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the week 5/3/2015 - 5/9/2015.
Client record # 3 contained a treatment plan dated 4/20/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the week 5/3/2015 - 5/9/2015.
Client record # 4 contained a treatment plan dated 11/5/2014 that identified the counseling services to be provided as individual therapy sessions 1 times per week. There were no individual therapy sessions scheduled for the client the weeks 11/9/2014 - 12/27/2014 and 2/1/2015 - 2/28/2015.
Client record # 5 contained treatment plans dated 12/22/2014 and 2/10/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 2/1/2015 - 2/7/2015 and 2/22/2015 - 2/28/2015.
Client record # 8 contained treatment plans dated 2/2/2015 and 3/9/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks 2/15/2015 - 2/21/2015 and 4/12/2015 - 4/18/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each client record will have documented a service or non-service according to the frequency that is written on each treatment. Each clinician will document if session is missed or rescheduled for each week to coincide with frequency. This will be monitored by program director and senior counselor each week. All clinicians will be required to bring client record to supervision and weekly team clinical meetings. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in six of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed on 5/14/2015. The facility failed to document a complete record in client records # 4, 5, 6, 7, 8, 9 and 10.
Client # 4 was admitted on 10/9/2014 and discharged on 3/2/2015. There was no documentation of a record of service for October 2014, November 2014, December 2014, January 2015, February 2015 and March 2015.
Client # 5 was admitted on 9/8/2014 and discharged on 3/3/2015. There was no documentation of a record of service for September 2014, October 2014, November 2014, December 2014, January 2015, February 2015 and March 2015.
Client # 6 was admitted on 10/17/2014 and discharged on 2/2/2015. There was no documentation of a record of service for November 2014, December 2014, January 2015 and February 2015.
Client # 7 was admitted on 10/22/2014 and discharged on 3/9/2015. There was no documentation of a record of service for October 2014, November 2014, December 2014, January 2015, February 2015 and March 2015.
Client # 8 was admitted on 1/12/2015 and discharged on 4/23/2015. There was no documentation of a record of service for January 2015, February 2015, March 2015 and April 2015.
Client # 9 was admitted on 1/14/2015 and discharged on 4/1/2015. There was no documentation of a record of service for January 2015, February 2015, March 2015 and April 2015.
Client # 10 was admitted on 11/17/2014 and discharged on 4/1/2015. There was no documentation of a record of service for November 2014, December 2014, January 2015, February 2015, March 2015 and April 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Record of Service will be completed for each client record upon filing clinical documentation on a daily basis. This will be monitored by program director and senior counselor on a weekly basis along with administrative assistant. For records 4, 5, 6, 7, 8, 9 and 10, the Record of Service was completed on 6/19/15. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment and rehabilitation plans for medical assistance clients as required by the Office of Medical Assistance in one of four client records reviewed.
The findings include:
Four client records requiring a physician signature on individual treatment and rehabilitation plans were reviewed on 5/14/2015. The individual treatment and rehabilitation plan contained in client record # 2 did not contain a physician signature as required by the Office of Medical Assistance.
Client # 2 was admitted to outpatient treatment on 3/25/2015 and was still an active client at the time of the inspection. The client's individual treatment and rehabilitation plan dated 4/25/2015 did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each medical assistant chart will be given to the doctor for his signature this will be reviewed by program director and senior counselor on a weekly basis to ensure that all documentation for medical assistant client records will have the signature of the doctor. Client 2's treatment plan was signed on 6/26/15. |